Asian Cardiovasc Thorac Ann 2000;8:169-171
© 2000 Asia Publishing EXchange Pte Ltd
Mycotic Aneurysm of Suprarenal Aorta in a 14-Year-Old Boy
Serdar Akgün, MD,
Ali Civelek, MD,
Figen Akalin, MD1,
Department of Cardiovascular Surgery
1 Department of Pediatric Cardiology
Marmara University School of Medicine
Istanbul, Turkey
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For reprint information contact: Serdar Akgün, MD Tel: 90 216 325 9133 Fax: 90 216 325 2426 email: serdarak{at}turk.net Department of Cardiovascular Surgery, Marmara University School of Medicine, Tophanelio lu Cad. 13-15, Altunizade, Istanbul 81190, Turkey.
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Abstract
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An extremely rare case of suprarenal mycotic aortic aneurysm of the abdominal aorta, secondary to tuberculous infection in a 14-year-old boy is reported. He required a Dacron graft implantation with visceral arterial reimplantation on an emergency basis. The patient died in the early postoperative period because of bleeding due to disseminated intravascular coagulation.
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Introduction
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Aneurysms of the abdominal aorta are rare; congenital abnormalities, inflammation, connective tissue diseases, and trauma are the most common causes.1 In children, mycotic aneurysms are very rare arterial lesions that arise usually from embolization of infectious material into normal aortic wall or from umbilical artery catheterization.2,3 The sites where mycotic aneurysms most frequently occur are the aortic arch and the abdominal visceral arteries.2 Usually, there is penetration by infection through the aortic wall, resulting in a false aneurysm or frank rupture.4 Mycotic abdominal aneurysm secondary to tuberculosis is extremely rare, particularly in a child.4,5
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Case Report
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A 14-year-old boy was referred because of spiking fevers, weight loss, and abdominal and back pain, which began 15 days before admission. His temperature was 39.1°C, blood pressure was 100/60 mm Hg, and heart rate was 100 beats•min–1. The abdomen was not distended but palpation, especially on the inguinal region, and percussion on the left costovertebral region were painful. Urine analysis showed pyuria and liver enzymes were mildly elevated. Abdominal ultrasonography suggested thrombosis in the abdominal aorta. The erythrocyte sedimentation rate was 28 mm•h–1 and C-reactive protein was 36.7 mg•L–1. Chest radiography showed a miliary appearance in spite of a negative purified protein-derivative skin test and direct acid-resistant bacteria screening. Bone marrow aspiration and culture was nonspecific. All other laboratory tests were normal. Careful reexamination of history revealed a tuberculous patient who was a coworker of our patient. Antimicrobial treatment for pyelonephritis and tuberculosis was started but his fever and abdominal pain did not respond. Abdominal computed tomography revealed intraabdominal lymphadenopathies and a saccular aortic aneurysm with intraluminal thrombosis. Digital subtraction angiography disclosed a suprarenal aortic mycotic aneurysm with a diameter of 5 cm (Figure 1
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Surgery was undertaken because of persistent high fever and abdominal pain. A left thoracoabdominal incision was performed and the aneurysm was dissected in left-sided retroperitoneal fashion. Visualization of the entire aorta was not possible because of a diffuse hematoma. The aneurysm ruptured spontaneously during the initial examination phase. The diaphragm was immediately opened and the aorta was clamped. Severe bradycardia developed during this phase. A second clamp was applied to the terminal aorta. The patient's heart rate returned to normal after massive transfusion and the aneurysm was opened. The aneurysm was approximately 6 cm in diameter and 10 cm in length. The entire aneurysmal section of the aortic wall was destroyed except for the anterior wall. All visceral arteries were prepared as a single Carrel patch for reimplantation and perfused with cold Ringer's lactate solution using balloon-tipped perfusion catheters. The in situ Dacron tube graft was interposed between the diaphragmatic level of the aorta and the proximal end of the inferior mesenteric artery, which was not affected by the disease. The Carrel patch was reimplanted into the Dacron tube graft. The crossclamp period was 36 minutes. Omental pedicle was used to surround the graft. There was persistent bleeding from the suture holes without signs of clotting. Rapid transfusion of fresh blood, cell-saver blood, and fresh frozen plasma resulted in acceptable clotting. The thoracoabdominal incision was closed in the usual manner and the patient was transferred to the intensive care unit.
The first postoperative hours were uneventful but the patient started to bleed later from the drainage tubes in the thorax and abdomen, and even from the skin incision. Disseminated intravascular coagulation was confirmed by checking all coagulation parameters. The bleeding could not be stopped, the patient developed cardiac arrest and died on the first postoperative day, in spite of intensive medical treatment. Histopathologic examination of the resected abdominal wall showed features of granulomatous inflammation (Figure 2). The adjacent lymph node and lung tissue revealed tuberculous lymphadenitis.
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Figure 2. Histopathologic examination of the resected aortic wall indicating granulomatous inflammation (hematoxylin and eosin stain, original magnification x40).
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Discussion
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The pathogenesis of mycotic aneurysm is thought to be embolomycotic or due to extension either directly or via lymphatics, or from hematogenous seeding of the arterial wall during bacteremia, leading to destruction of the vessel wall, aneurysm formation, and rupture.4 Commonly involved organisms include Staphylococcus aureus, Staphylococcus epidermidis, subspecies of Salmonella, Streptococcus, Pseudomonas, Enterobacter, Proteus, and Yersinia, Haemophilus influenzae, Campylobacter fetus, Bacteroides fragilis, Candida, and Escherichia coli.2,5 Mycobacterium infections have only been reported secondary to bacille Calmette-Guérin vaccine.6
Suprarenal mycotic abdominal aneurysms present a formidable surgical problem as they exhibit a strong tendency towards early rupture with a very high mortality.4 Surgical management of mycotic aneurysms and choice of graft material is still controversial. The options are either placement of an in situ graft or bypassing the aorta with extraanatomical prosthetic grafts or allografts.4,7,8 We preferred to operate in situ without delay because of the high risk of death with medical therapy alone and because of the prevalence of rupture. An in situ graft was preferred because all the visceral arteries arose from the aneurysmal part of the aorta. A Dacron graft had to be used because of unavailability of allografts at the time. Some authors have recommended allograft material to reduce the rate of late postoperative infections and improve survival.7 Omental flap was used to surround the graft to fill dead space and stop oozing from the suture line. During this operation, exsanguinating hemorrhage before proximal and distal control of the abdominal aorta may be fatal even with massive blood transfusion and bloodsaving techniques. Postoperative progressive disseminated intravascular coagulation may contribute to a fatal outcome, as in this case.
Although successful treatment of mycotic aneurysm of the abdominal aorta has been reported, exsanguinating hemorrhage is still a major surgical problem.1,2 We consider that despite its rarity, a successful outcome can be achieved by timely diagnosis, detailed preoperative evaluation, and well-planned surgery and postoperative care.
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References
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Abstract
Introduction
